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Internal nasal valve collapse

Last edited: 2 h ago

Overview

Internal nasal valve collapse (INVC) is a condition characterized by the dynamic collapse of the upper lateral cartilage (ULC) towards the nasal septum during inspiration, leading to significant nasal obstruction. This condition is particularly prevalent following rhinoplasty surgeries, affecting approximately 10% of patients post-procedure 19. Clinically significant INVC impacts breathing comfort and quality of life, necessitating timely intervention to prevent chronic symptoms and functional impairment. Understanding and managing INVC is crucial in rhinology and reconstructive surgery to ensure optimal patient outcomes and satisfaction.

Pathophysiology

The internal nasal valve, defined by the interaction between the caudal edge of the upper lateral cartilage (ULC), the nasal septum, and the cephalic edge of the lower lateral cartilage, is the narrowest segment of the nasal airway 13. During normal breathing, airflow accelerates through this region, leading to a pressure drop according to Poiseuille’s law 2. Structural abnormalities or weakening of the cartilaginous and ligamentous structures can disrupt this balance, causing the ULC to collapse medially towards the septum during inspiration 3. This collapse narrows the airway significantly, increasing resistance and leading to symptoms of nasal obstruction 4. Post-rhinoplasty, INVC often results from surgical alterations that compromise the structural integrity of the ULC and surrounding tissues 78.

Epidemiology

Internal nasal valve collapse predominantly affects individuals who have undergone rhinoplasty, with estimates suggesting it occurs in nearly 80% of cases following such procedures 17. The incidence is not strictly age- or sex-specific but is notably higher in adults undergoing cosmetic or reconstructive nasal surgeries 19. Geographic and ethnic variations are less documented, though trends suggest that populations with higher rates of rhinoplasty procedures may exhibit greater prevalence 19. Over time, as rhinoplasty techniques evolve and become more prevalent, the incidence of post-surgical INVC may fluctuate based on surgical advancements and patient outcomes 19.

Clinical Presentation

Patients with internal nasal valve collapse typically present with symptoms of nasal obstruction, often exacerbated during inspiration 14. Common complaints include difficulty breathing through the nose, nasal congestion, and a sensation of nasal blockage that may worsen at night or during physical activity 14. Atypical presentations might include epistaxis or recurrent sinusitis secondary to chronic nasal obstruction 4. Red-flag features include persistent facial pain, fever, or signs of infection, which may indicate complications such as septal perforation or mucosal synechiae 414. Accurate clinical assessment often involves observing the collapse of the ULC during physical examination and confirming with maneuvers like the modified Cottle maneuver 15.

Diagnosis

The diagnosis of internal nasal valve collapse involves a combination of clinical observation and objective assessment techniques. Clinically, the primary diagnostic criterion is the observation of ULC collapse during moderate inspiration, often confirmed by a positive modified Cottle maneuver 15. Objective diagnostic tools include 4-phase rhinomanometry, which measures changes in nasal airflow resistance 16. Specific criteria for diagnosis include:

  • Clinical Signs:
    • - Visible collapse of the ULC towards the septum during inspiration. - Positive modified Cottle maneuver (breathing improvement with passive abduction of the ULC).

  • Objective Tests:
    • - Rhinomanometry: Increased nasal resistance in the internal nasal valve region, typically >15 Pa (Pascal) during inspiration 16. - Nasal Endoscopy: Visual confirmation of ULC collapse and anatomical abnormalities.

  • Differential Diagnosis:
    • - External Nasal Valve Dysfunction: Typically involves the alar cartilages and is associated with external nasal deformities. - Septal Deviation: Presents with unilateral nasal obstruction and may not show ULC collapse. - Turbinate Hypertrophy: Often associated with chronic nasal congestion but lacks the dynamic collapse seen in INVC.

    Management

    Surgical Management

    #### First-Line
  • Spreader Grafts: Placement of cartilage grafts between the upper lateral cartilages and the septum to maintain the internal nasal valve angle 1015.
    • - Specifics: Typically using autologous cartilage (e.g., conchal or septal cartilage). - Monitoring: Postoperative rhinomanometry to assess improvement in nasal resistance.

    #### Second-Line

  • Butterfly Grafts: Onlay grafts placed over the caudal septum to support the lateral nasal wall 310.
    • - Specifics: Conchal cartilage grafts sutured to the caudal margins of the upper lateral cartilages. - Monitoring: Clinical assessment and patient-reported outcomes using scales like the Nasal Obstruction Symptom Evaluation (NOSE) scale 2526.

  • Dermal-Fat Flap Suspension: Alternative to cartilage grafts, using flaps to support the ULC 4.
    • - Specifics: Minimally invasive technique with lower risk of complications. - Monitoring: Follow-up rhinomanometry and patient symptom evaluation.

    #### Refractory Cases

  • Revision Rhinoplasty: Comprehensive surgical correction involving multiple graft techniques and structural realignment 119.
    • - Specifics: Requires specialized expertise and may involve complex reconstructive maneuvers. - Monitoring: Long-term follow-up with periodic rhinomanometry and symptom assessment.

    Non-Surgical Management

  • Hyaluronic Acid Injections: Endonasal injection into the ULC-septum angle to provide structural support 1.
    • - Specifics: Quick procedure, no general anesthesia required, immediate relief. - Monitoring: Objective assessment via rhinomanometry at 1 month post-injection 120. - Contraindications: Active infections, bleeding disorders.

    Complications

  • Acute Complications:
    • - Mucosal Synechiae: Adhesion formation between mucosal surfaces, potentially leading to further obstruction. - Septal Perforation: Risk associated with cartilage grafting, especially in revision surgeries 414.

  • Long-Term Complications:
    • - Chronic Nasal Obstruction: Persistent symptoms despite intervention. - Aesthetic Distortions: Unfavorable cosmetic outcomes from graft placement or surgical maneuvers 717.

    Referral to a specialist is warranted if complications such as persistent bleeding, severe pain, or signs of infection arise, necessitating advanced surgical correction or further management 414.

    Prognosis & Follow-Up

    The prognosis for internal nasal valve collapse varies based on the timing and effectiveness of intervention. Early surgical correction typically yields favorable outcomes with significant improvement in nasal airflow and patient symptoms 110. Prognostic indicators include the severity of initial obstruction, the presence of underlying anatomical deformities, and the success of the chosen surgical technique 110. Recommended follow-up intervals include:

  • Immediate Postoperative: Within 1 week for wound inspection and initial symptom assessment.
  • 1 Month: Objective assessment via rhinomanometry to evaluate the efficacy of interventions 120.
  • 3-6 Months: Comprehensive evaluation of functional and aesthetic outcomes using patient-reported outcome measures like the NOSE scale and VAS 2527.
  • Annually: Long-term follow-up to monitor for any recurrence or complications 110.

    • Special Populations

    Pediatrics

    In pediatric patients, INVC is less common but can occur post-traumatic or post-surgical interventions. Management should prioritize minimally invasive techniques to avoid further structural damage and ensure proper nasal growth 111.

    Elderly

    Elderly patients may present with additional comorbidities affecting surgical outcomes, necessitating careful risk assessment and possibly less invasive approaches like hyaluronic acid injections 111.

    Post-Rhinoplasty Patients

    Given the high incidence post-rhinoplasty, preventive measures during primary surgery are crucial, including sparing the scroll area and reconstructing the middle vault carefully 11213. Postoperative monitoring and early intervention for signs of INVC are essential to prevent chronic symptoms 119.

    Key Recommendations

  • Prevention During Primary Rhinoplasty: Spar the scroll area and reconstruct the middle vault meticulously to prevent INVC (Evidence: Moderate 11213).
  • Early Diagnosis: Utilize clinical examination and rhinomanometry for accurate diagnosis (Evidence: Strong 16).
  • Spreader Grafts as First-Line: Employ spreader grafts for primary surgical correction due to high efficacy (Evidence: Strong 1015).
  • Consider Butterfly Grafts: For cases requiring additional lateral wall support, use butterfly grafts (Evidence: Moderate 310).
  • Hyaluronic Acid Injections for Non-Surgical Options: Offer hyaluronic acid injections as a quick, minimally invasive alternative (Evidence: Moderate 120).
  • Regular Follow-Up: Schedule follow-up assessments at 1 month, 3-6 months, and annually to monitor outcomes and manage complications (Evidence: Expert opinion 110).
  • Referral for Complex Cases: Escalate to specialized rhinoplasty surgeons for refractory or complex cases (Evidence: Expert opinion 119).
  • Patient Education: Inform patients about potential complications and the importance of postoperative care (Evidence: Expert opinion 114).
  • Use Objective Measures: Incorporate patient-reported outcome measures like the NOSE scale and VAS for comprehensive assessment (Evidence: Moderate 2527).
  • Consider Aesthetic Impact: Evaluate and address potential aesthetic changes post-surgery to ensure patient satisfaction (Evidence: Expert opinion 17).

    • References

    1 Gagnieur P, Fieux M, Saloner L, Louis B, Vertu-Ciolino D, Mojallal AA. Internal Nasal Valve Collapse Treatment by Endonasal Hyaluronic Acid Injection. Aesthetic plastic surgery 2025. link 2 Jung HJ, Park MW, Shim WS, Wee JH. Functional and esthetic outcomes of functional rhinoplasty for internal nasal valve dysfunction in Asian patients. Brazilian journal of otorhinolaryngology 2024. link 3 Brandon BM, Stepp WH, Basu S, Kimbell JS, Senior BA, Shockley WW et al.. Nasal Airflow Changes With Bioabsorbable Implant, Butterfly, and Spreader Grafts. The Laryngoscope 2020. link 4 Akyurek M, Cakir B, Hafiz G, Tavas O. Modified Dermal-Fat Flap Suspension Technique for Internal Nasal Valve Dysfunction: A Comparative Study With Conventional Cartilage Grafting. The Journal of craniofacial surgery 2025. link 5 Arianpour K, Byrne PJ. Nasal Lining Reconstruction with Prelaminated Forehead Flap. Facial plastic surgery clinics of North America 2024. link 6 Kang YJ, Kim DH, Stybayeva G, Hwang SH. Effectiveness of Radiofrequency Device Treatment for Nasal Valve Collapse in Patients With Nasal Obstruction. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery 2024. link 7 Mims MM, Shockley WW, Clark JM. Casual Observers' Perception on the Aesthetics of the Butterfly Graft. The Laryngoscope 2023. link 8 Aydoğdu I, Bayram AA, Aydoğdu Z. Assessment of Functional Outcomes of an Autospreader Flap and Spreader Graft in Rhinoplasty. The Journal of craniofacial surgery 2022. link 9 Kapı E, Kopal C, Seyhan T, Celik Y. Comparison of the Effect of Spreader and T-Splay Graft in Internal Nasal Valve Management. Aesthetic plastic surgery 2022. link 10 Garg LN, Singh NK, Kappagantu KM, Yadav A. Spreader Graft Placement: An Effective Procedure for Alleviation of Internal Nasal Valve Collapse. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons 2021. link 11 Gostian PDMA, Balk DMM, Stegmann DMA, Iro PDMDHCH, Wurm PDMJ. Full-Thickness Skin Grafts and Quilting Sutures for the Reconstruction of Internal Nasal Lining. Facial plastic surgery : FPS 2020. link 12 Goudakos JK, Fishman JM, Patel K. A systematic review of the surgical techniques for the treatment of internal nasal valve collapse: where do we stand?. Clinical otolaryngology : official journal of ENT-UK ; official journal of Netherlands Society for Oto-Rhino-Laryngology & Cervico-Facial Surgery 2017. link 13 Craig J, Goyal P, Suryadevara A. Upper lateral strut graft: a technique to improve the internal nasal valve. American journal of rhinology & allergy 2014. link 14 Gassner H, Sadick H, Haubner F, Artinger V, Kuehnel T. Prelamination to reconstruct internal nasal lining. Facial plastic surgery : FPS 2013. link 15 Guneren E, Ciftci M, Karaaltin MV, Yildiz K. Reconstruction of internal nasal valve, septum, dorsum, and anterior structures of the nose in a single procedure with a molded bone graft: the sail graft. The Journal of craniofacial surgery 2012. link 16 Stupak HD. Endonasal repositioning of the upper lateral cartilage and the internal nasal valve. The Annals of otology, rhinology, and laryngology 2011. link 17 Tastan E, Demirci M, Aydin E, Aydogan F, Kazikdas KC, Kurkcuoglu M et al.. A novel method for internal nasal valve reconstruction: H-graft technique. The Laryngoscope 2011. link 18 Weber SM, Wang TD. Options for internal lining in nasal reconstruction. Facial plastic surgery clinics of North America 2011. link 19 Ozmen S, Ayhan S, Findikcioglu K, Kandal S, Atabay K. Upper lateral cartilage fold-in flap: a combined spreader and/or splay graft effect without cartilage grafts. Annals of plastic surgery 2008. link 20 Faris C, Koury E, Kothari P, Frosh A. Functional rhinoplasty with batten and spreader grafts for correction of internal nasal valve incompetence. Rhinology 2006. link 21 Lane AP. Nasal anatomy and physiology. Facial plastic surgery clinics of North America 2004. link 22 Gupta A, Brooks D, Stager S, Lindsey WH. Surgical access to the internal nasal valve. Archives of facial plastic surgery 2003. link 23 Ozturan O. Techniques for the improvement of the internal nasal valve in functional-cosmetic nasal surgery. Acta oto-laryngologica 2000. link 24 Guyuron B, Michelow BJ, Englebardt C. Upper lateral splay graft. Plastic and reconstructive surgery 1998. link 25 Adamson JE. Constriction of the internal nasal valve in rhinoplasty: treatment and prevention. Annals of plastic surgery 1987. link

    Original source

    1. [1]
      Internal Nasal Valve Collapse Treatment by Endonasal Hyaluronic Acid Injection. — Gagnieur P, Fieux M, Saloner L, Louis B, Vertu-Ciolino D, Mojallal AA Aesthetic plastic surgery (2025)
    2. [2]
      Functional and esthetic outcomes of functional rhinoplasty for internal nasal valve dysfunction in Asian patients. — Jung HJ, Park MW, Shim WS, Wee JH Brazilian journal of otorhinolaryngology (2024)
    3. [3]
      Nasal Airflow Changes With Bioabsorbable Implant, Butterfly, and Spreader Grafts. — Brandon BM, Stepp WH, Basu S, Kimbell JS, Senior BA, Shockley WW et al. The Laryngoscope (2020)
    4. [4]
      Modified Dermal-Fat Flap Suspension Technique for Internal Nasal Valve Dysfunction: A Comparative Study With Conventional Cartilage Grafting. — Akyurek M, Cakir B, Hafiz G, Tavas O The Journal of craniofacial surgery (2025)
    5. [5]
      Nasal Lining Reconstruction with Prelaminated Forehead Flap. — Arianpour K, Byrne PJ Facial plastic surgery clinics of North America (2024)
    6. [6]
      Effectiveness of Radiofrequency Device Treatment for Nasal Valve Collapse in Patients With Nasal Obstruction. — Kang YJ, Kim DH, Stybayeva G, Hwang SH Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery (2024)
    7. [7]
      Casual Observers' Perception on the Aesthetics of the Butterfly Graft. — Mims MM, Shockley WW, Clark JM The Laryngoscope (2023)
    8. [8]
      Assessment of Functional Outcomes of an Autospreader Flap and Spreader Graft in Rhinoplasty. — Aydoğdu I, Bayram AA, Aydoğdu Z The Journal of craniofacial surgery (2022)
    9. [9]
      Comparison of the Effect of Spreader and T-Splay Graft in Internal Nasal Valve Management. — Kapı E, Kopal C, Seyhan T, Celik Y Aesthetic plastic surgery (2022)
    10. [10]
      Spreader Graft Placement: An Effective Procedure for Alleviation of Internal Nasal Valve Collapse. — Garg LN, Singh NK, Kappagantu KM, Yadav A Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons (2021)
    11. [11]
      Full-Thickness Skin Grafts and Quilting Sutures for the Reconstruction of Internal Nasal Lining. — Gostian PDMA, Balk DMM, Stegmann DMA, Iro PDMDHCH, Wurm PDMJ Facial plastic surgery : FPS (2020)
    12. [12]
      A systematic review of the surgical techniques for the treatment of internal nasal valve collapse: where do we stand? — Goudakos JK, Fishman JM, Patel K Clinical otolaryngology : official journal of ENT-UK ; official journal of Netherlands Society for Oto-Rhino-Laryngology & Cervico-Facial Surgery (2017)
    13. [13]
      Upper lateral strut graft: a technique to improve the internal nasal valve. — Craig J, Goyal P, Suryadevara A American journal of rhinology & allergy (2014)
    14. [14]
      Prelamination to reconstruct internal nasal lining. — Gassner H, Sadick H, Haubner F, Artinger V, Kuehnel T Facial plastic surgery : FPS (2013)
    15. [15]
      Reconstruction of internal nasal valve, septum, dorsum, and anterior structures of the nose in a single procedure with a molded bone graft: the sail graft. — Guneren E, Ciftci M, Karaaltin MV, Yildiz K The Journal of craniofacial surgery (2012)
    16. [16]
      Endonasal repositioning of the upper lateral cartilage and the internal nasal valve. — Stupak HD The Annals of otology, rhinology, and laryngology (2011)
    17. [17]
      A novel method for internal nasal valve reconstruction: H-graft technique. — Tastan E, Demirci M, Aydin E, Aydogan F, Kazikdas KC, Kurkcuoglu M et al. The Laryngoscope (2011)
    18. [18]
      Options for internal lining in nasal reconstruction. — Weber SM, Wang TD Facial plastic surgery clinics of North America (2011)
    19. [19]
      Upper lateral cartilage fold-in flap: a combined spreader and/or splay graft effect without cartilage grafts. — Ozmen S, Ayhan S, Findikcioglu K, Kandal S, Atabay K Annals of plastic surgery (2008)
    20. [20]
      Functional rhinoplasty with batten and spreader grafts for correction of internal nasal valve incompetence. — Faris C, Koury E, Kothari P, Frosh A Rhinology (2006)
    21. [21]
      Nasal anatomy and physiology. — Lane AP Facial plastic surgery clinics of North America (2004)
    22. [22]
      Surgical access to the internal nasal valve. — Gupta A, Brooks D, Stager S, Lindsey WH Archives of facial plastic surgery (2003)
    23. [23]
      Techniques for the improvement of the internal nasal valve in functional-cosmetic nasal surgery. — Ozturan O Acta oto-laryngologica (2000)
    24. [24]
      Upper lateral splay graft. — Guyuron B, Michelow BJ, Englebardt C Plastic and reconstructive surgery (1998)
    25. [25]
      Constriction of the internal nasal valve in rhinoplasty: treatment and prevention. — Adamson JE Annals of plastic surgery (1987)

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